Critical care physicians often think they are providing futile care and the cost of that care is substantial, researchers reported.

Action Points

This single-center study demonstrated that some ICU care is perceived as futile by treating physicians.

Be aware that virtually all patients in whom care was perceived as futile had bad outcomes and none were living independently.

Critical care physicians often think they are providing futile care and the cost of that care is substantial, researchers reported.

In a short single-institution study, intensivists reported they thought the care they were delivering was futile 11% of the time and probably futile in another 8.6%, according to Thanh Huynh, MD, of the University of California Los Angeles, and colleagues

Over a 3-month period, the futile care cost was an estimated $2.6 million, Huynh and colleagues reported online in JAMA Internal Medicine.

But the findings should be interpreted with caution, argued Robert Truog, MD, of Harvard Medical School, and Douglas White, MD, of the University of Pittsburgh School of Medicine.

Among other things, they wrote in an accompanying commentary, while the cost of futile care in the study is substantial, it's unlikely that eliminating such care would save the whole amount because about 85% of intensive care unit (ICU) costs are fixed.

If that's taken into account, the "more modest potential savings" should be compared with other targets, such as cutting down on excess imaging and lab tests, before embarking on projects to eliminate perceived futile care.

They added that decisions on which interventions are futile are controversial and "often have divisive effects on clinicians, patients, and families."

Nevertheless, interventions that prolong life but will not achieve an outcome that patients can "meaningfully appreciate" are often perceived to be futile by health care providers, the researchers noted.

To try to clarify the extent of such care and its costs, Huynh and colleagues asked a focus group of intensivists to try to define the term. From that discussion, they created a short questionnaire that asked doctors in five intensive care units (ICUs) at an academic health care system to pick out patients the physicians believed were receiving futile care.

Of those patients, 904 (or 80%) were never perceived to be receiving futile treatment, Huynh and colleagues reported, while 98 (or 8.6%) were thought to be receiving probably futile treatment, 123 (or 11%) were thought to be getting futile treatment, and 11 (or 1%) were perceived as receiving futile treatment but only on the day they transitioned to palliative care.

Most commonly, treatment was perceived as futile because "the burdens grossly outweighed the benefits," the researchers reported. But doctors also often said treatment was futile because it could never reach the patient's goals, death was imminent, or the patient would never be able to survive outside an ICU.

The investigators also reported:

Patients who had futile care received 464 days of treatment, or 6.7% of all assessed patient days in the five ICUs.

Of the 123 patients perceived as receiving futile treatment, 84 died before discharge and 20 within 6 months of ICU care, for a 6-month mortality rate of 85%. Those who survived had severely compromised health states.

On average, the cost for a day of treatment that was perceived to be futile was $4,004, which added up to $2.6 million for the 123 patients categorized as getting such care -- or 3.5% of total hospital costs for the 1,136 patients in the study, Huynh and colleagues reported.

The researchers cautioned that the study might not apply widely, since it is based on a single health system that provides resource-intensive treatment. They added that there were no objective criteria for futility; in particular, families might not have agreed with physician assessments.

The study was supported by a donation from Mary Kay Farley to RAND Health. The journal said the authors reported no conflicts of interest.

The journal said the commentary authors reported no conflicts of interest.

Reviewed by F. Perry Wilson, MD, MSCE Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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